The Vulva During Childhood
Girls’ vulva and vagina are particularly susceptible to various clinical conditions because of their anatomy, their lack of estrogen exposure, and frequent contact with irritants. In this chapter we will analyze the girl’s anatomy and how it differs from
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The Vulva During Childhood Adriadna Caussade
8.1
Anatomy of the Vulva in Girls
The transient effect of maternal estrogen fades within the first 6 months of the infant’s life. Consequently, before puberty, the anatomy of a girl’s vulva differs significantly from the adult woman’s. Contrary to the adult vulva, the girl’s is hairless and has very little subcutaneous fat, both in the labia majora and the mons pubis. This makes girls more prone to deep bruising and injuries when they are exposed to trauma, so frequent in childhood. The labia minora look atrophic and are barely noticeable; consequently, the introitus opens widely, and the vagina is more readily exposed to injuries; in addition, the very short distance from the anus to the introitus favors local inflammation and infections [1, 2]. The apocrine glands of the labia majora, prepuce, vestibulum vaginae, and perineal body are not activated until puberty; as a result, the conditions associated with these structures are rare in childhood. However, the sweat glands do function before puberty, and their obstruction may cause sudamen, a condition frequently seen in neonates [1]. During childhood, the hymen is a vascularized mucous membrane that separates the vagina from the introitus. It may vary in size, thickness, and shape. The normal diameter is about 1 cm, and its compliance is quite limited A. Caussade (*) Clínica de Tracto Genital Inferior, Montevideo, Uruguay
until estrogen begins to act in puberty. The most common shapes observed tend to be annular, in crescents, or fimbriated. In some cases, a small slit observed at 6 o’clock may be a remnant of hymenal septae, and not necessarily a sign of abuse. However, the presence of clefts at three or nine would suggest that possibility. There are some developmental or permeabilization abnormalities, including cribriform, septate [2], or even imperforate hymens, which can lead to primary amenorrhea and hematometra, which is corrected by making an incision in the hymen and thus releasing any accumulated vaginal and uterine discharge.
8.2
Physical Examination of the Girl
For a satisfactory examination, it is important to achieve a good rapport between the doctor and parents or caregivers but especially between the doctor and the child [3]. The examining doctor should be affectionate but not fawning. If the physical examination is impossible at the first visit, it should be left for the second, and if it continues to be difficult, or if the case is urgent and really warrants anesthesia, then this latter procedure should not be spared [4]. The physical examination of the girl is done by placing her in a frog position, her legs falling sideways, and gently pulling them to the side, to allow a partial view of the vagina (Fig. 8.1). The Valsalva
© Springer International Publishing AG, part of Springer Nature 2019 J. Bornstein (ed.), Vulvar Disease, https://doi.org/10.1007/978-3-319-61621-6_8
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A. Caussade
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Fig. 8.2 Direct visualization of a worm at the perianal area. Pinworms cause pruritus. Courtesy
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